Prevention and Treatment of Postpartum Depression

Pharmacological Treatment

A number of studies have pointed out that Postpartum Depression (PPD) is essentially the same as Major Depression (MDD) and, therefore, benefits from pharmacological treatment with antidepressant medication, but very few studies have conducted randomized controlled trails comparing different medication and placebos.1 In general, pharmacological treatment of MDD has proven to be just as effective as psychological interventions.2 However, the adverse effects on breastfeeding and infant well-being remain largely unknowns and medication has to be prescribed with caution.1, 2 An extensive review by Fitelson and associated1 outlines several open studies that have established fluoxamine, sertraline, bupropion, nefazodone and venlafaxine as effective pharmacological treatment for PPD. Yet, the validity and generalizability of these studies is limited by small sample sizes (4 to 15 participants) and tainted by pharmacological companies’ sponsorship. In  cases where patients have responded well to a particular antidepressant in the past, experts advise practitioners to choose the same medication for the treatment of PPD.1,3

Pharmacological Treatment as a Preventative Measure

There is some evidence that pharmacological treatment can have preventative properties as well. A randomized placebo-controlled pilot study by Wisner and colleagues (2004)4 has shown that sertraline treatment started shortly after delivery prevented women with history of PPD from experiencing another episode. Yet, these results remain inconclusive and more research is needed to establish the role of antidepressants in PPD prevention.

Pharmacological Treatment’s Effect on the Child

The major concerns surrounding pharmacological treatment of PPD revolve around its effect of lactation, breastfeeding and infant well-being.1 Infants are particularly vulnerable to the effects of medication, due to their immature blood-brain barrier, hepatic and renal systems and still developing neurological systems and brain structures.5 Still, research on the effects of antidepressants on the baby through maternal breastfeeding is very limited and largely contains of small studies with questionable external validity, and isolated case studies.1 Some researchers have deducted that sertraline and paroxetine, among the Selective Serotonin Reuptake Inhibitors, are least likely to be detected in the infant’s system and adverse effects have rarely been observed.5 In comparison, citalopram and fluoxetine, appear to be more readily transmitted through breast milk. Their effects range from sleep changes in the infant to more serious respiratory, gastrointestinal problems and even seizures.5 In addition, antidepressants in infants have been correlated with increased plasma levels.1 Although the observed effects among infants have been of mild to moderate severity and have remitted after the mother discontinued medication use, there are no guarantees there will be no effects in the long run. In addition, research has not determined whether lack of clinically significant amounts of antidepressants in the baby’s system actually means the child is not affected in any way.1 These concerns suggest the need for further research, including more longitudinal studies.

Why Medication May Not be The Best Option

The benefits of breastfeeding have been extensively studied and firmly established by prominent organizations, such as the World Health Organization, the American Academy of Family Practitioners and the American Academy of Pediatrics, all of which recommend breastfeeding for at least six months after birth.6,7,8 Considering this, most clinicians recommend non-pharmacological treatment for cases of mild or moderate depression, especially since these can be just as effective, but without the risk of side effects.1 Yet, if pharmacological treatment is initiated, experts suggest that the baby’s pediatrician is immediately informed and begins to routinely examine for possible exposure and monitor any changes of sleeping and feeding patterns, sedation, irritability and other signs of drug toxicity1.1,9

Research has demonstrated the effectiveness of psychological and psychosocial treatments of PPT, which also bypass the risk of side effects and infant drug toxicity.1, 10

Interpersonal Therapy

Interpersonal therapy (IPT) has been suggested as effective psychological treatment for PPD and women who received IPT had a significant decrease in PPD symptomatology.11 The typical course of IPT lasts for 12 to 20 weeks and focuses on four main interpersonal problem areas: role transition, role dispute, interpersonal deficits and grief. Clients are encouraged to transform their problematic interpersonal approaches into more healthy and adaptive ones, which is expected to improve the mother-infant and  mother-partner relationships and help the new mother for the upcoming transition back to work.11 It has been further established that a group format of IPT may have benefits compared to individual therapy, as it increases social support, helps new mothers improve their interpersonal skills, allows for realization of the normality of the symptoms and issues and reduces the stigma associated with PPD.1

Cognitive behavioral Therapy

Cognitive Behavioral Therapy (CBT) is another therapeutic modality that has proven no be beneficial in the treatment of depression, including PPD.1,12,13 The main focus in CBT is to help clients modify their distorted cognitive patterns and negative thinking and initiate behavioral changes that will enhance their coping and reduce distress.13,14 Fitelson and associates1 have reviewed a study where only six sessions of CBT correlated with significant decrease of depressive symptoms in postpartum women. A pilot study by Cho and colleagues (2008)13 has examined antenatal CBT as a way of primary prevention. The intervention incorporated classic CBT components for treatment of depression and components aiming at enhancing marital relationship and communication. Their CBT intervention proved effective in reducing automatic negative thoughts, marital dissatisfaction and communication dissatisfaction. This individual CBT intervention not only improved well-being during pregnancy, but also during the postpartum period. The authors’ conclusion is that individually-tailored CBT intervention is more effective than a group format. However, if group sessions are the only option, helping professionals should avoid issues around personal fatigue, the condition of the unborn baby and dissatisfaction from partner.13 One key hypothesis in these studies is that interventions  that improve the quality of the marital relationship have great preventative power for PDD, as they increase both actual and perceived support.

Person-Centered Therapy

Person-centered counseling, also referred to as non-directive counseling, has also shown to decrease depressive symptoms in postpartum women in a number of randomized controlled studies.1

Social Support

Lack of adequate social support is among the first risk factors for PPD, therefore peer and partner support groups have received a lot of attention among researchers.1 Dennis (2003)15 has studied the effects of mother-to-mother support over telephone communication and has observed the beneficial effects of this approach. In fact, the severity of depressive symptoms was significantly reduced in eight weeks. Additionally, women who have been identified as high risk for developing PPD were involved in telephone-based peer support over 12 weeks and were later recorded to have lower incidence of PPD when compared to a control group. This gives hope that these noninvasive and cost-effective therapeutic approaches can also serve as preventative measures.

Alternative Therapies

Interesting research by Field and colleagues (1996)16 has shown that teaching new mothers to massage their infant reduces irritability and sleep problems in the baby, while leading to reduced depression in the mother. This massage therapy is a relatively simplistic techniques with potential to greatly benefit both the mother, child and their interaction. Findings like these increase our hopes that researchers will establish new methods of prevention and treatment which can transform the prevalence rates of PPD among new mothers.

References:

1. Fitelson, E., Kim, S., Baker, A. S., & Leight, K. (2011). Treatment of postpartum depression:clinical, psychological and pharmacological options. International Journal of Women’s Health, 3, 1-14.
2. Bledsoe, S. E. & Grote, N. K. (2006). Treating depression during pregnancy and in the postpartum: a preliminary meta-analysis. Research on Social Work Practice, 16, 109–120.
3. Wisner, K. L., Parry, B. L., & Piontek, C. M. (2002). Postpartum depression. The New England  Journal of Medicine, 347(3), 194-199.
4. Wisner, K. L., Perel, J. M., Peindl, K. S., Hanusa, B. H., Piontek, C. M., & Findling, R. L.  (2004). Prevention of postpartum depression: a pilot randomized clinical trial. American Journal of Psychiatry, 161, 1290–1292.
5. Burt, V. K., Suri, R., Altshuler, L., Stowe, Z., Hendrick, V., C., & Muntean, E. (2001). The use of psychotropic medications during breast-feeding. American Journal of Psychiatry, 158, 1001–1009.
6. American Academy of Family Physicians (2008). Breastfeeding, Family Physicians Supporting (Position Paper).
7. American Academy of Pediatrics Committee on Drugs (2001). The transfer of drugs and other chemicals into human milk. Pediatrics, 108(3), 776-789.
8. World Health Organization (2002). The optimal duration of exclusive breastfeeding: report of an expert consultation, Geneva Switzerland 2001 Mar 28–30. Department of Nutrition for Health and Development, Department of Child and Adolescent Health and Development.
9. The Academy of Breastfeeding Medicine Protocol Committee (2008). ABM Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. Breastfeeding Medicine, 3(1), 44–52.
10. Dennis, C. L. & Chung-Lee, L. (2006). Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systemic review. Birth, 33, 323–331.
11. Stuart, S. & O’Hara, M. W. (1995). Interpersonal psychotherapy for postpartum depression: a treatment program. Journal of Psychotherapy Practice and Research, 4, 18–29.
12. Butler, A. C. & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3-5.
13. Cho, H. J., Kwon, J. H., & Lee, J. J. (2008). Antenatal cognitive-behavioral therapy for prevention of postpartum depression: a pilot study. Yonsei Medical Journal, 49(4), 553-562.
14. Hollon, S.D. (1998). What is cognitive behavioural therapy and does it work? Current Opinions in Neurobiology, 8, 289–292.
15. Dennis, C. L. (2003). The effect of peer support on postpartum depression: a pilot randomized controlled trial. Canadian Journal of Psychiatry, 48(2), 115–124.
16. Field, T., Grizzle, N., Scafidi, F., & Abrams, S. (1996). Massage therapy for infants of depressed mothers. Infant Behavior and Development, 13, 107–112.

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